Neurosurgical apparatus



Dec. 12, 1967 e. N. NEWELL NEUROSURGICAL APPARATUS 4 Sheets-Sheet 1Filed March 5, 1965 R m m l o w Q Q in NM m. W, 4 mp? QM. W \N f 0 0 evWW 7 v- ATiORNEYS Dec. 12, 1967 G. N. NEWELL 3,357,431

NEUROSURGICAL APPARATUS Filed March 3, 1965 4 Sheets-Sheet 2 INVENTOR650261 NOD05? A/f/VL ZL XMW ATTORNEYS Dec. 12, 1967 G. N. NEWELL3,357,431,

NEUROSURGICAL APPARATUS Filed March 5, 1965 4 Sheets-Sheet 5 Z kgINVENTOR 7 6.50265 M0005? Milt [Z1 1 iwk W ATTORNEYS Dec. 12, 1967 G. N.NEWELL 3,357,431

NEUROSURGI CAL APPARATUS Filed March 3, 1965 4 Sheets-Sheet 4 III [IIIlllllllllllllll Hllllllllllllllllllun lulluullml m INVENTOR smea #00051Niki/64L- BY MW A TORNEY5 United States Patent Ofifice 3,357,43lPatented Dec. 12, 1967 3,357,431 NEUROSURGICAL APPARATUS George NodderNewell, Edinburgh, Scotland, assignor to Allen & Hanburys Limited,London, England, a British company Filed Mar. 3, 1965, Ser. No. 436,73411 Claims. (Cl. 128-403) ABSTRACT OF THE DISCLOSURE The presentinvention involves stereotactic neurosurgical apparatus used forlocating lesions in the brain.

This application is a continuation-in-part of my copending US.application Ser. No. 41,693, filed July 8, 1960, now abandoned.

The present invention is concerned with neurosurgical apparatuses. Moreparticularly, the present invention relates to a stereotacticneurosurgical apparatus useful for strategically placing lesions as atreatment or part of the treatment for certain nervous disorders,intractable pain and psychiatric disorders. The relief of the moredistressing symptoms of Parkinsonism and other hyperkinetic disorders bythe production of destructive coagulative lesions of the brain bydiathermy or chemical means is becoming an accepted surgical procedure.In surgical procedures of this kind, it is essential to ensure that thelesion is located with extreme accuracy and that the apparatus usedshould enable the production of the minimum lesion consistent withrelief of the condition to be treated. It is desirable, too, that itshould be possible to apply the apparatus to the head of a patient witha minimum amount of discomfort to the patient and in as short a time aspossible consistent with accuracy.

Stereotactic devices are known but all suffer from one or moredisadvantages such as the distress caused the patient when the procedureis lengthy, the degree of accuracy in localizing the site of the lesionis less than is desirable, the method of adjustment is difficult andinconvenient for the surgeon or there is the risk that the position ofthe apparatus will inadvertently be altered Iduring the operation, suchas by movement of the patients ead.

An object of the present invention is to provide an instrument capableof insuring the production of surgical destructive coagulative lesionsof the brain by diathermy or chemical meanswith greater accuracy thanwas hitherto possible and which overcomes the disadvantages of the knownapparatuses.

The present invention provides a surgical stereotactic instrumentcomprising a crest frame adapted to be fixed to the cranium of a patientalong the mid-sagittal plane and a carriage, to which the rest of theinstrument is attached, which includes sights positioned one on eachside of the head of the patient, the sights being movable togetherbackwards and forwards, and upwards and downwards with respect to theframe, treatment supporting means carried by the frame so as to belocated in a fixed position determined by the adjustment of the frameand treatment means.

The preferred embodiments of the invention are illusrated in theaccompanying drawings wherein:

FIGURE 1 is a perspective view of the stereotactic instrument placed onthe head of a patient to be treated;

FIGURE 2 is a sectional view taken along lines 2-2 of FIGURE 1;

FIGURE 3 is a sectional view taken along lines 33 of FIGURE 2;

FIGURE 4 is a sectional view taken along lines 44 of FIGURE 1;

FIGURE 5 is a sectional view taken along lines 5--5 of FIGURE 1;

FIGURE 6 is a sectional view taken along lines 66 of FIGURE 5;

FIGURE 7 is a sectional view taken along lines 77 of FIGURE 1;

FIGURE 8 is a view similar to that in FIGURE 2 of a modified embodiment;I

FIGURE 9 is a sectional view taken along lines 9) of FIGURE 8.

For convenience of description the instrument is herein described withthe parts of the instrument in the positions which they occupy when theinstrument is fittted to the head of a patient during a neurosurgicaloperation. Before the instrument is fitted on the cranium of a patient,three screws A, A and A" are placed in the outer table of the skullaccording to a simple procedure to be described. There is a constantanatomical relationship between the globus pallidus, and the thalamus,the anterior and posterior commissures and the mid-sagittal plane of thehead.

Thus, the first step in using this stereotactic instrument to treat apatient is to inspect the patients cranium, and to note the positions ofthe lamboid and interparietal sutures. Knowledge of the anatomy of thebrain, then enables a prediction to be made of the approximate positionof the mid-sagittal plane, i.e. the mid-line of the brain. A series ofsmall lead shots are inserted into holes made in the skull at threepoints astride the mid-saggital lane as predicted. Air is then injectedinto the ventricular system and subarachnoid space of the brain andsince the air is less opaque than the surrounding brain, an X-ray filmshows the position of the anterior and posterior commissures, and theexact position of the mid-sagittal plane. The inserted lead shots,having been placed in three groups each of which is astride the midline,appear on the X-ray film. One shot in each group can be seen to lie onthe exact mid-saggital plane. Each of the three shots lying along thatplane is removed and replaced by screws A, A and A" which are left inpermanently.

The stereotactic instrument can then be put in place. This instrumentcomprises a main crest frame 1 adapted to be fitted lengthwise on thecranium of a patient in the manner of a crest of a helmet. Threelocating screws 2, 2' and 2 rotatable in the frame 1 engage screws A, Aand A" thus fixing the frame in position in the central longitudinalplane of the head of a patient. These locating screws have knurled upperor outer heads 3, 3' and 3" which can be rotated to adjust the spacingof the frame from the patients head. Slidable carriage 4 to which all ofthe rest of the instrument is attached, slides into the crest frame 1and is clamped in place by rotating knurledheaded screw 5. The body ofthe instrument can be moved in the central longitudinal plane of thehead of the patient by movement of the carriage 4 along the frame 1.This movement is most easily accomplished by providing carriage 4 withlips 4a and crest frame 1 with spaced rails 1a. Carriage 4 can then heslid onto the crest frame 1 at any place where there is a space in therails 1a and clamped in the desired position by tightening screw 5.

The frame 1 and the carriage 4 are provided with a scale 32 and anindicator 33 to enable the relative positions of the carriage and theframe to be accurately fixed. A support column 6 comprising telescopingportions 6a and 6b is mounted on a horizontally rotatable cylinder 28and extends vertically upwards from the carriage. A screw 7 with aknurled head 8 fits inside the column 6. When it is desired to adjustthe height of the column 6 upward or downward with respect to the frame,such is accomplished merely by rotating knurled head 8. A calibratedscale 34 is provided on the telescoping sections 6a and 6b to assistaccurate positioning of the height of column 6. The position of thecolumn 6 is adjus'ted radially (in a plane parallel with the centrallongitudinal plane of the head of the patient) by rotation of knurledhead 9 of arm 10. This arm extends above the carriage connected to thecylinder 28 and rotates worm gearing 31. The worm gearing 31 is rotatedby screw'10 forward or backward to the desired position. A screw 30'locks the gears and cylinder in the desired position.

A cross-arm or support bar 12 is attached near the top of support column6 and extends transversely above the head of the patient in a horizontalplane. Cross-arm 12 ha's'a slot 13 through which an electrode 14 can bepassed. Extending vertically downwards from near each end of thecross-arm are vertical sight arms 15 and 16. The

lower ends of these sight arms carry sight means 17 and 18. These meanspreferably comprise one radio-opaque ring on one arm and a stud on theother, both pref e'r'ably being'm'oiinted in a radio-translucent Tufnel.The sights can be rotated on an arc by turning arm 10' or they may bemoved upward or downward by turning knurled head 8'. With the aid ofradiography, these sights can be used to select a portion of the brainto be treated. This portion is hereinafter referred to as point X.

The horizontal cylinder 28 mounted on the carriage 4 has a scale portionthereon 19 and a longitudinal slot 20 therethrough. Sleeve 21 ismountedon cylinder 28 and carries guide tube 22 for an electrode which passesthrough slot 20. This guide tube 22 and sleeve 21 can be placed iii adesired position by slidih'g' them along the slot 20 and clamping themin place by tightening knurled headed screw 23. The calibrated scaleportion 19 provides accurate positioning of the sleeve and guide tube.

Treatment means 14 preferably comprises a tipped electrode having anadjustable stop member 24. This electrode passes through slot 13 andthrough guide tube 22 to contact the area to betreated.

The various movable parts of the instrument are adjustable at will sothat they can be correctly arranged with respect to point X.

A handle 25 extends upwards from the frame 1 and is mounted so that itsposition backwards and forwards on the frame can be adjusted. Thishandle 25 has two handgrips 26 and 27, extending in opposite directionslengthwise of the frame. One of these grips is for use by the surgeon,-whose hands will always be sterile during an operation, and the other isfor use by the radiologist Whose hands may not necessarily be sterileduring the opera tion. The handgrips are used to adjust the position ofthe patients head by setting the grips at a convenient angle for thesurgeon and radiologist who then directly adjust the position of thepatients head by moving the handle, without disturbing the setting ofthe instrument. This is because the head and instrument move as a unit.

To determine point X, the treatment point, a radioopaque agent isinjected to outline the anterior commissure. For. practical purposes theglobus pallidus lies 3 mm. posterior to the anterior commissure and 1mm. below the intercommissural line. The sights 17 and 18 are aligned onthis area and are adjusted to the correct position by the two knurledheads 8 and 9. Knurled head 8 moves the sights up and down while knurledhead 9 moves them on an arc. The radiologist, by the use of an X-rayimage intensifier, can see the sights and position them correctly inrelation to the anterior commissure as described above. By this meansthe target area, point X, is known to be between the two sights.

Inspection of the X-ray film earlier obtained, and knowledge of theanatomy of the brain enables the position of the globus pallidus alongthe sight line to be calculated. This is normally 16 mm. from themidline although enlargement of the third ventricle increases thismeasurement proportionally. The sleeve 21 which carries the electrodeguide tube 22 is moved 16 mm. to one side of the midline as measured onthe calibrated scale 19 of the cylinder 28. The sleeve is clamped inposition by screw 23. A hole is made in the occipital region of theskull immediately below the electrode guide tube. The electrode stop 24is adjusted so that in use the electrode tip will lie on the target linebetween the sights.

To effect treatment electrode 14 is then passed gently through slot 13,guide tube 22 into the hole in the patients head, through the occipitallobe and into the thalamus. The contact .of the electrode with thepulvinar or posterior end of the thalamus can be clearly felt by thesurgeon. Confirmation that the electrode is in the thalamus is evidenton low voltage stimulation since the patient experiences a tinglingsensation at the side of the mouth and between the thumb and indexfinger. Electro-coagulation is carried out for a set period of time byapplying a predetermined voltage to the electrode. The patient isobserved during this period and tremor is often damped down and maydisappear. Certain symptomatic occurrences may be followedby the surgeonto enable him to decide upon the length of treatment required. Theelectrode 14 is pushedfurther into the brain to its final target in theglobus pallidus. Electro-coagulation is again carried out.

The electrode is withdrawn and replaced by a tube t, through which astainless steel ball b is placed as a marker in the lesion. Thestereotactic instrument is then removed from the head.

In a modified embodiment of the present invention, cylinder 28 extendslengthwise in the horizontal plane so that sight arms 15 and 16 passthrough it at 15a and (FIGURE 8). A further modification includes anadditional guide tube 22' attached to and extending through the sleeve21 at an angle for guiding electrode 14 atan angle. This enables theelectrode 14 to be introduced into the skull at an angle so that the endis brought nearer the center line (see guide tube 22, FIGURE 8). Wherithe guide tube 22' is added, a curso'rand scale 40are provided. Theseare clipped on to the instrument as shown in FIGURE 8, prior to the timeat which the apparatus is placed on the patients head, to facilitateexact calculation of the position of the electrode.

Other and further uses of and for. the aforedescribed invention will beappreciated by thoseskilled in that art by reference to thisspecification and the appended claims.

What is claimed is:

1. A surgicalstereotactic instrument which comprises:

(a) a crest frame adapted to be fitted to the cranium of a patient to betreated along the mid-sagittal plane;

(b) a carriage movably attached to the crest frame;

(0) a cylinder attached transversely to said carriage;

(d) a column mounted on the cylinder and extending vertically upwardtherefrom;

(e) a cross-arm having a slot therethrough attached substantiallyperpendicularly to said column and when fitted to a patients headextending across the patients cranium transverse to the mid-sagittalplane thereof;

(f) two sight arms, one attached near each end of the cross-arm, botharms extending vertically in the same plane as the column;

(g) two sights, each of which are attached to the distal ends of thesight arms;

(h) a guide tube slidably attached to the cylinder; and

(i) treatment means passing through the slot in the cross-arm. andguided by the guide tube to contact the point to be treated.

2. An instrument according to claim 1 which further comprises:

(a) a handle having at least one hand grip affixed to and extendingupward from the carriage;

(b) gear means attached to the carriage and the cylinder; and

(c) a knob operating a shaft for turning the gear means, whereby as thegear is turned the cylinder rotates in the horizontal plane and thecolumn moves in an are substantially along the mid-sagittal plane.

3. An instrument according to claim 2 which further comprises:

(a) a scale disposed on the crest frame; and

(b) indicator means to determine and show the relative position of thecarriage along the frame.

4. An instrument according to claim 3 which further comprises:

(a) a scale portion on the cylinder, said cylinder also having a slottherethrough along the scale portion; and

(b) a sleeve to which said guide means is attached, which sleeve isattached to the cylinder and is slidable along the length of the slotthrough the scale portion, the guide means being disposed on the sleeveso as to extend through the slot in the scale portion;

whereby as the sleeve is slid along the cylinder the scale on thecylinder shows the position of the sleeve and guide means.

5. An instrument according to claim 4 wherein the column comprises atleast two telescoping sections and a knurled head operating screw meansconnected thereto so that when the head is rotated in one direction thecolumn rises and when the head is rotated in the opposite direction thecolumn closes.

6. An instrument according to claim 5 wherein the sights comprise aradio-opaque ring attached at the distal end of one cross-arm and a studattached at the distal end of the other cross-arm.

7. An instrument according to claim 6 wherein the treatment meanscomprises a tipped electrode having an adjustable stop member whereby,when the electrode passes through the slot in the cross-arm and theguide tube into the patients head, the stop member limits the downwardtravel of the electrode by contacting the upper surface of the slot.

8. A surgical stereotactic instrument which comprises:

(a) a crest frame having rails along its outer surfaces adapted to beremovably secured to the cranium of a patient to be treated along themid-sagittal plane;

(b) a carriage having a mating means attached to the crest frame andslidable along the rails;

(c) a scale disposed upon the frame;

(d) indicator means to determine and show the relative position of thecarriage on the frame;

(e) a cylinder rotatably attached to the carriage transverse to itslongitudinal axis and having a scale portion thereon and a slotextending through the scale portion along the length thereof;

(f) a column mounted on the cylinder and extending vertically upwardtherefrom comprising at least two telescoping sections;

(g) a knurled head operating screw means attached to the innermostsection of the column so that rotation of the head in one directioncauses the column to rise and rotation of the head in the oppositedirection causes the column to telescope closed;

(h) a cross-arm having a slot therethrough attached to the upper portionof the innermost section of the column and extending transversely of themid-sagittal plane of the patients cranium;

(i) two sight arms, each of which is attached to the cross-arm near itsend;

(j) two sights comprising a radio-opaque ring and a stud, the ring beingattached at a distal end of one sight arm and the stud being attached atthe distal end of the other sight arm;

(k) a sleeve disposed around the cylinder and attached to the tubetherein so that movement of the sleeve causes the tube to extend fromand retract back into the cylinder;

(1) a guide tube attached to the sleeve and extending therethrough andthrough the slot in the scale portion in a substantially verticalposition;

(m) means for temporarily securing the sleeve in a desired position;

(n) a tipped electrode sized to fit through the slot in the cross-armand to pass through the guide tube into the patients head in a hole madefor treatment;

(0) a stop member adjustably afiixed to the electrode to limit thedownward travel of the electrode by contacting the upper surface of theslot;

(p) gear means attached to the cylinder and the carriage;

(q) means for turning the gear means and thus rotating the cylinder inthe horizontal plane; and

(r) a handle attached to the carriage having two hand grips at the upperend thereof.

9. An instrument according to claim 8 wherein the cylinder has slotsthrough its ends and the sight arms pass through the slots.

10. An instrument according to claim 9 comprising an additional guidetube attached to and extending through the sleeve at an angle andextending through the slot in the scale portion at an angle.

11. An instrument according to claim 10 comprising a scale and cursorremovably attachable t0 the frame and carriage for calculating theposition of the angled electrode.

References Cited UNITED STATES PATENTS 11/1962 Dobbeleer c 128303 XR12/1965 Vladyka et al. l28-303 XR

1. A SURGICAL STEREOTACTIC INSTRUMENT WHICH COMPRISES: (A) A CREST FRAMEADAPTED TO BE FITTED TO THE CRANIUM OF A PATIENT TO BE TREATED ALONG THEMID-SAGITTAL PLANE; (B) A CARRIAGE MOVABLY ATTACHED TO THE CREST FRAME;(C) A CYLINDER ATTACHED TRANSVERSELY TO SAID CARRIAGE; (D) A COLUMNMOUNTED ON THE CYLINDER AND EXTENDING VERTICALLY UPWARD THEREFROM; (E) ACROSS-ARM HAVING A SLOT THERETHROUGH ATTACHED SUBSTANTIALLYPERPENDICULARLY TO SAID COLUMN AND WHEN FITTED TO A PATIENT''S HEADEXTENDING ACROSS THE PATIENT''S CRANIUM TRANSVERSE TO THE MID-SAGITTALPLANE THEREOF; (F) TWO SIGHT ARMS, ONE ATTACHED NEAR EACH END OF THECROSS-ARM, BOTH EXTENDING VERTICALLY IN THE SAME PLANE AS THE COLUMN;(G) TWO SIGHTS, EACH OF WHICH ARE ATTACHED TO THE DISTAL ENDS OF THESIGHT ARMS; (H) A GUIDE TUBE SLIDABLY ATTACHED TO THE CYLINDER; AND (I)TREATMENT MEANS PASSING THROUGH THE SLOT IN THE CROSS-ARM AND GUIDED BYTHE GUIDE TUBE TO CONTACT THE POINT TO BE TREATED.